| Survey |
| Please fill out survey questions. We hope to be able to use the results to help get the treatment that is needed for chronic pain patients. All answers will be kept confidential. |
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Please fill in the blanks. Fields marked with * are Required.
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Name: |
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Email Address: |
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City: |
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State: |
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Have you ever been called a drug seeker by a doctor?: |
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Is your pain being properly controlled by medication?: |
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Have you felt suicidal because of uncontrolled pain?: |
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Are you able to work?: |
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Do you feel you could work if on the proper medication?: |
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Comments: |
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